Enteral tubes: administration of medication via (PICU)

Administering medicines via enteral feeding tubes is a process that can change the way medicines are absorbed and handled by the body. There are some medicines that are more affected than others.

There are also some issues around the licensing of medicines that are crushed, opened or otherwise changed to facilitate administration down an enteral feeding tube. As such, the ORAL route should always be used in preference to enteral feeding tubes.

This is often not possible in critical care environments when children are heavily sedated, with endo-tracheal tubes in situ rendering oral administration of medications unsafe. It is thus essential that oral medicines are administered via enteral feeding tubes. 

Soluble tablets:

• Dissolve the required number of tablets in a suitable volume of sterile potable water.
• If the whole tablet dose is to be administered, rinse out the vessel in which the tablet was dissolved with sterile potable water, draw up into the same syringe used to administer the dose, and administer this residue to ensure the full dose is given.
• If only a part dose is to be administered, ensure the resulting solution from the dissolved tablet is well suspended by continually agitating the solution. Administer the dose IMMEDIATELY

Tablets:

• Crush the tablet in a tablet crusher
• Mix the resultant powder with an appropriate volume of sterile potable water
• If the whole tablet dose is to be administered, rinse out the vessel in which the tablet was dissolved with sterile potable water, draw up into the same syringe used to administer the dose, and administer this residue to ensure the full dose is given.
• If only a part dose is to be administered, ensure the resulting solution from the dissolved tablet is well suspended by continually agitating the solution. Administer the dose IMMEDIATELY

Capsules:

• Carefully open the capsule and allow its contents to fall into a suitable container
• Disperse this powder with an appropriate volume of sterile potable water
• If the whole tablet dose is to be administered, rinse out the vessel in which the tablet was dissolved with sterile potable water, draw up into the same syringe used to administer the dose, and administer this residue to ensure the full dose is given.
• If only a part dose is to be administered, ensure the resulting solution from the dissolved tablet is well suspended by continually agitating the solution. Administer the dose IMMEDIATELY

Liquids (including injectable products to be given enterally):

• Shake the container well (for at least 15 seconds)
• Draw up the required volume for the dose
• Thick liquids should be diluted with 2 to 3 times the volume with sterile potable water. This makes them less likely to “clog” in the tube. 

DO NOT flush enteral tubes with the same syringe used to administer the dose as enteral syringes have a “dead-space” which is accounted for on the graduations.

Enteric coated medicines (denoted e/c on packaging, label or in the BNF.)

• Modified Release medicines (denoted CR, MR, SR, XL, LA, Once-Weekly on packaging, label or in the BNF.)
• Cytotoxic medicines
• Hormones
• Tablets designed for administration sub-lingually (with the exception on Desmomelts), buccally, or that should be chewed 

Most medicines are absorbed jejuno-ileally thus there are few restrictions on what can be given via a post-pyloric feeding tube. However, these tubes tend to be much narrower than gastric feeding tubes, and thus are more prone to blockage.

FLUSHING is the single most important factor in ensuring post-pyloric tube maintenance. If unsure, contact pharmacy for advice.

Proton Pump Inhibitors
Omeprazole, lansoprazole, esomeprazole and others (see BNF)

• Antacid products
  Gaviscon ®, Gaviscon Infant ®, Peptac ®, sucralfate

• Has a narrow therapeutic index
  i.e e. Drugs which require monitoring of levels